Emergency Department Visits for Pedestrians Injured in Motor Vehicle Traffic Crashes — United States, January 2021–December 2023

Traffic-related pedestrian deaths in the United States reached a 40-year high in 2021. Each year, pedestrians also suffer nonfatal traffic-related injuries requiring medical treatment. Near real-time emergency department visit data from CDC's National Syndromic Surveillance Program during January 2021-December 2023 indicated that among approximately 301 million visits identified, 137,325 involved a pedestrian injury (overall visit proportion = 45.62 per 100,000 visits). The proportions of visits for pedestrian injury were 1.53-2.47 times as high among six racial and ethnic minority groups as that among non-Hispanic White persons. Compared with persons aged ≥65 years, proportions among those aged 15-24 and 25-34 years were 2.83 and 2.61 times as high, respectively. The visit proportion was 1.93 times as high among males as among females, and 1.21 times as high during September-November as during June-August. Timely pedestrian injury data can help collaborating federal, state, and local partners rapidly monitor trends, identify disparities, and implement strategies supporting the Safe System approach, a framework for preventing traffic injuries among all road users.


Introduction
In 2021, approximately 7,000 pedestrians were killed in motor vehicle crashes, the most in 40 years (1).During 2009-2016, approximately 47,000 traffic-related hospital admissions occurred annually among pedestrians (2).Data commonly used to assess pedestrian injuries, such as nationally representative probability sampled surveys of hospitals and police crash reports, might have time lags of ≥2 years between pedestrian visit proportion (visit proportion), defined as the number of pedestrian visits per 100,000 total ED visits, was calculated overall and by race and ethnicity,** age group (0-14, 15-24, 25-34, 35-64, and ≥65 years), sex (female and male), season (autumn [September-November], winter [December-February], spring [March-May], and summer [June-August]), and U.S. Department of Health and Human Services (HHS) region.† † Visit ratios, with corresponding Wald 95% CIs, were calculated as the visit proportion of a given group divided by the visit proportion of a specified referent group.§ § Because data quality and coding practices can vary by facility and over time, analyses were restricted to EDs that more consistently reported complete data (coefficient of variation ≤40% and average weekly informative discharge diagnosis ≥75% complete during 2021-2023).After this restriction, 81% of all ED visits and 82% of all pedestrian ED visits were used.¶ ¶ Analyses were conducted using Base R (version 4.2.2;Posit).This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy.***** Race and ethnicity are categorized as non-Hispanic White, non-Hispanic Black or African American, non-Hispanic American Indian or Alaska Native, non-Hispanic Native Hawaiian or Pacific Islander, non-Hispanic Asian, non-Hispanic multiracial or another race, and Hispanic or Latino.† † https://www.hhs.gov/about/agencies/iea/regional-offices/index.html;https:// www.cdc.gov/nssp/participation-coverage-map.html§ § Referent groups are defined as the groups with the lowest proportions for pedestrian injury ED visits per 100,000 visits.

Results
The weekly number of pedestrian visits during the 3-year period (January 2021-December 2023) generally peaked during autumn.Weekly pedestrian visits mostly followed the pattern of all ED visits, with the exception that pedestrian visits flattened during summer while all ED visits increased (Figure ).
Among approximately 301 million ED visits, 137,325 involved a pedestrian injury, resulting in an overall visit proportion of 45.62 pedestrian injury ED visits per 100,000 total ED visits.Compared with the visit proportion among non-Hispanic White (White) persons, visit proportions were 2.47 times as high among non-Hispanic multiracial persons or persons of another race, 2.23 times as high among non-Hispanic Asian (Asian) persons, 2.13 times as high among non-Hispanic American Indian or Alaska Native (AI/AN) persons, 1.93 times as high among non-Hispanic Black or African American (Black) persons, 1.70 times as high among Hispanic or Latino (Hispanic) persons, and 1.53 times as high among non-Hispanic Native Hawaiian or Pacific Islander persons (Table ).Compared with the visit proportion among persons aged ≥65 years, visit proportions were 2.83 times as high among persons aged 15-24 years, 2.61 times as high among those aged 25-34 years, 2.18 times as high among those aged 35-64 years, and 1.25 times as high among those aged 0-14 years.The visit proportion was 1.93 times as high among males as among females.Compared with visit proportions during summer, the visit proportion was highest during autumn (visit ratio = 1.21).Compared with visit proportion in HHS Region 7 (Iowa, Kansas, Missouri, and Nebraska), the visit proportion was 4.29 times as high in HHS Region 2 (New Jersey and New York).

Discussion
Using syndromic surveillance data from January 2021-December 2023, the proportion of ED visits related to pedestrian injury was highest among six racial and ethnic minority groups.The racial and ethnic disparities in this report are consistent with previous studies.For example, among patients in the U.S. Nationwide Inpatient Sample during 2009-2016, admission rates were elevated among Black, Hispanic, and  ).† † Patients missing ethnicity were categorized as non-Hispanic and based on documented race.Patients missing race data and who were not documented as Hispanic or Latino (Hispanic) were categorized as missing.Persons of Hispanic origin might be of any race but are categorized as Hispanic; all racial groups are non-Hispanic.§ § https://www.hhs.gov/about/agencies/iea/regional-offices/index.html;https://www.cdc.gov/nssp/participation-coverage-map.htmlmultiracial persons and persons of another race (2).Pedestrian death rates nationwide during 2018 were higher among AI/AN and Black persons than among White persons (3).However, the visit proportion in the current study was higher among Asian persons than among White persons, whereas pedestrian death rates in 2018 indicated the reverse (3).Unsafe walking environments and limited investment in infrastructure for pedestrians (e.g., sidewalks, street lighting, and crosswalks) can result from past development that prioritized vehicles (4) and historical segregation and disinvestment in neighborhoods based on race and income (5).Healthy community design strategies exist that address pedestrian injury inequities while minimizing harms, such as displacement, that can occur among persons from some racial and ethnic groups and with lower incomes (6).
In addition to racial and ethnic inequities, differences were also found by sex, age, season, and region.The higher proportion of pedestrian visits among males aligns with 2021 pedestrian death rates (1).The visit proportion was highest among persons aged 15-24 years compared with other age groups.This finding differs from 2021 pedestrian death rates, which were highest among adults aged 60-64 years (1), likely because of increasing frailty with age (7).The pedestrian visit proportion was highest during autumn, as was the number of pedestrian deaths in traffic crashes during 2020-2021.† † † Variation in regional visit proportions might be influenced by differences in pedestrian volume or population density.§ § § Risk factors for pedestrian injury are generally multifactorial and can include exposure to vehicles traveling at high speeds, alcohol involvement on the part of the driver or pedestrian, and insufficient visibility.Slowing vehicles by narrowing or reducing lanes, reducing speed limits, or using automated speed cameras can protect pedestrians, as can improving crossing safety and separating pedestrians from vehicles through new or improved sidewalks (8,9).In 2021, an estimated 19% of crashes resulting in pedestrian deaths involved drivers with blood alcohol concentrations of ≥0.08 g/dL (1).Despite proven effectiveness of stricter blood alcohol limits (9), only one state, Utah, has lowered its legal blood alcohol concentration from 0.08 to 0.05 g/dL.In the year after the law went into effect, the motor vehicle crash death rate per mile driven decreased 18% in Utah, compared with a 6% decrease in the rest of the United States (10).Most pedestrian traffic deaths (77% in 2021) occurred after dark (1).Enhancing visibility through strategies such as street lighting can help reduce pedestrian traffic deaths.
A comprehensive approach involving collaboration among federal, state, and local partners could help prevent pedestrian injuries and address social and structural inequities † † † https://www.cdc.gov/injury/wisqars/fatal/trends.html

Limitations
The findings in this report are subject to at least five limitations.First, NSSP data are not nationally representative.Second, ¶ ¶ ¶ https://publichealth.jhu.edu/sites/default/files/2023-03/recommendationsof-the-safe-system-consortium.pdf**** https://www.nsc.org/roadtozero† † † † https://www.transportation.gov/NRSS§ § § § https://www.congress.gov/bill/117th-congress/house-bill/3684/textthis report includes only a percentage of U.S. EDs, and causes of injuries are not always documented in medical records; therefore, the weekly numbers of pedestrian injury ED visits are likely underestimates.Third, EDs might collect race and ethnicity data differently, which could result in misclassification.Fourth, detailed crash information such as vehicle speed, time of day, roadway and pedestrian infrastructure, and driver and pedestrian behavior (e.g., impairment) are not available in NSSP.Finally, differences in ED usage across groups, both general usage and that specific to pedestrian injuries, could affect results.

Implications for Public Health Practice
Findings from ED data on pedestrian injuries emphasize the need to prioritize prevention efforts for pedestrians.NSSP provides near real-time pedestrian injury data.These data can be analyzed at the local, state, and national levels to monitor the most recent trends, identify populations and areas most affected, and tailor implementation strategies supporting the Safe System approach, a framework designed to protect all road users.

FIGURE.
FIGURE.Weekly number of emergency department visits for pedestrian injury* -National Syndromic Surveillance Program, † United States, January 2021-December 2023

TABLE . Emergency department visits for pedestrian injury* per 100,000 total visits and visit ratios, by selected characteristics - National Syndromic Surveillance Program, † United States, January 2021-December 2023 Characteristic § Visit proportion ¶ Visit ratio** (95% CI)
NSSP is a collaboration among CDC, federal partners, local and state health departments, and academic and private sector partners.NSSP receives medical record data from approximately 78% of EDs nationwide, although <50% of facilities from California, Hawaii, Minnesota, and Oklahoma currently participate in NSSP.https://www.cdc.gov/nssp/index.html§ Percentage of missing data for total ED visits and for pedestrian injury ED visits was †